Diagnosis of Alcoholism in a Simulated Patient Encounter by Primary Care Physicians
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Diagnosis of Alcoholism in a Simulated Patient Encounter by Primary Care Physicians Richard L. Brown, MD, MPH, William B. Carter, PhD, and Michael J. Gordon, PhD Philadelphia, Pennsylvania, and Seattle, Washington Although early detection and treatment of alcoholism have been shown to be effi cacious, it is widely accepted that primary care physicians often fail to diagnose alcoholism. In this study, a computerized, simulated encounter with an alcoholic patient was used to assess the performance of a randomly selected sample of pri mary care physicians in diagnosing alcoholism. Of 95 physicians in this study, only 32 percent diagnosed alcoholism with maxi mal certainty. There was great variability among physicians in the threshold of in formation needed to diagnose alcoholism. One third of subjects misinterpreted symptoms of alcoholism and erroneously made other psychiatric diagnoses, chiefly anxiety or depression. Results of this pilot study were not associated with the physicians’ age, sex, specialty, duration of training, or reported personal impact of alcoholism. This study provides further evidence of the need for additional education of primary care physicians if such physicians are to succeed in reducing the dramatic im pact of alcoholism and alcohol abuse on public health. lcoholism and alcohol abuse are among the most have a sizable opportunity to improve the health outcomes A prevalent and serious public health problems in the of a large segment of their patient populations. nation, with 14 percent of the adult population estimated This study was an initial attempt to assess the perfor to be “symptomatic drinkers.”1 In 1980 the total mortality mance of practicing primary care physicians in diagnosing attributed to alcoholism in the United States was over early alcoholism by using a computerized, simulated pa 69,000.1 Additionally, alcohol abuse contributes substan tient encounter. It was intended that the results would tially to many morbid conditions,2 is linked to family dis provide an estimate of the frequency with which primary ruption, child abuse, and violence,2 3 and is estimated to care physicians might diagnose alcoholism in patients cost the nation as much as $116.7 billion yearly.1 similar to the simulated patient and, more important, that Alcoholism can be diagnosed before irreversible they would provide insight into aspects of physicians’ biomedical consequences have occurred,4-6 and, once di thought processes, which, if altered, might facilitate phy agnosed, it can be successfully treated.7-10 Nevertheless, sicians’ diagnosing of alcoholism. physicians often fail to diagnose alcohol problems,11-14 and when such problems are diagnosed, physicians often fail to attempt to treat them.14-18 Although from 10 to 40 METHODS percent of patients seen by physicians have alcohol prob lems,19 only 15 percent of all alcoholics are believed ever Subjects and Recruitment to receive treatment.20 Primary care physicians therefore Recruiting letters were mailed to a random sample of the approximately 400 board-certified family physicians and Submitted, revised, June 23, 1987. general internists (without subspecialty board certification) who were included on the mailing lists of the King County From the Department of Family Medicine, University of Washington, Seattle, (Washington) Medical Society. The letters offered two Washington, and the Department of Family Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania. This study was performed while Dr. Richard Brown category I continuing medical education (CME) credits, was a Robert Wood Johnson Fellow in Family Medicine, University of Washington, $25, and educational feedback in return for completing Seattle, Washington. Requests for reprints should be addressed to Dr. Richard i Brown, Department of Family Medicine, Thomas Jefferson University, 1015 a computerized, simulated patient encounter and a follow Walnut Street, Suite 401, Philadelphia, PA 19107. up questionnaire. Physicians were informed that the © 1987 Appleton & Lange the JOURNAL OF FAMILY PRACTICE, VOL. 25, NO. 3: 259-264, 1987 259 DIAGNOSIS OF ALCOHOLISM TABLE 1. CLUES TO THE DIAGNOSIS OF ALCOHOLISM IN TABLE 2. CLUES TO THE DIAGNOSIS OF ALCOHOLISM ON THE SIMULATED PATIENT THE ALCOHOL USE MENU 1. Drinking in response to stress 1. Admits greater alcohol consumption than previously 2. Marital discord 2. History of alcoholic blackouts 3. Difficulties at work 3. Previous attempts to decrease drinking 4. Recent change of job 4. Wife’s concern about patient’s drinking 5. History of a one-car motor vehicle accident 5. Patient’s guilt over his drinking 6. Paternal history of alcoholism 6. Morning consumption of alcohol 7. Failure to reduce coffee intake 8. Failure to reduce cigarette use 9. Feelings of discouragement about his situation 10. Sleep disturbance 11. No appetite disturbance appropriate certainty and to formulate a complete man 12. Slight weight gain agement plan. Each physician then performed a diagnostic 13. Slightly disturbed attention and concentration evaluation of the same simulated patient by means of a 14. Normal libido menu-driven computer program that was created for this 15. Slightly fatigued study. The menus presented physicians with over 600 de 16. No suicidal thoughts 17. No previous psychiatric history scriptions of pieces of clinical data that physicians could 18. Anxious feelings about work request on the patient. In so doing, physicians performed 19. Intermittently elevated blood pressure a history and physical examination, ordered and received 20. Blood alcohol level of 9 mmol/L (40 mg/dL) laboratory tests, and reviewed past medical records. The 21. Serum glutamic-oxaloacetic transaminase (SGOT) of 0.09 Mkat/L (54 U/L) computer program recorded the order in which each sub 22. Gamma glutamyltransferase of 5.07 /*kat/L (304 U/L) ject obtained various pieces of clinical data. Almost all 23. High-normal mean corpuscular volume physicians completed the exercise within 45 minutes. 24. Gastritis visible on gastroscopy The case was one of a 38-year-old male, married, in ventory control manager with recurrent abdominal pain. If appropriate items were selected, the history revealed symptoms of active peptic ulcer and gastritis and many study’s purpose would be to investigate how physicians clues to alcoholism,22,23 as shown in Table 1. Eighteen of would manage a particular patient in their practices. Full these clues were strictly historical, including the patient’s time physicians at the authors’ institution and close ac admission of drinking in response to stress. Several of quaintances of the authors were excluded. Ninety-five these historical clues, such as anxiety related specifically physicians (39 percent of those contacted) were enrolled to the patient’s job and a normal libido, were designed to in the study. More family physicians were recruited and help rule out a diagnosis of anxiety disorder or depression. enrolled because the supply of general internists was ex Five clues were laboratory results, and one, high blood hausted. Differences between the participation rates of pressure, was obtainable by history, physical examination, family physicians and general internists were not statis and past medical records. tically significant. Throughout the exercise, the assistant encouraged the physicians to request additional information not found on the computer menus. Three additional menus dealing The Computerized, Simulated with marital and family problems, stress, and alcohol use Patient Encounter were made available by the assistant if physicians ex Initially, the computerized, simulated case was pretested pressed an interest in these specific areas. Responses to on six faculty members, including two with special ex items on the alcohol-use menu provided further infor pertise in alcoholism. The case fulfilled the Diagnostic mation on the extent of the patient’s drinking problem and Statistical Manual of Mental Disorders, Third Edition (Table 2). (DSM III) criteria for a diagnosis of alcohol abuse but not Immediately after completing the exercise, subjects for any other psychiatric diagnosis based on DSM III cri were given a questionnaire on which they indicated the teria.21 Other correct diagnoses were gastritis and peptic likelihood that the patient had any of 11 diagnoses—gall ulcer. All six faculty members found the case to be realistic bladder disease, gastritis, gastrointestinal tumor, pancre and the correct diagnoses to be accurate. atitis, peptic ulcer, alcohol problem, anxiety disorder, A trained research assistant administered the simulation depression, malingering, personality disorder, and so to each physician on a portable microcomputer, usually matization disorder— on a five-point Likert-type scale: in the physician’s office. Each physician was instructed to very likely, somewhat likely, intermediate, somewhat un obtain sufficient information to make a diagnosis with likely, and very unlikely. 260 THE JOURNAL OF FAMILY PRACTICE, VOL. 25, NO. 3, 1987 DIAGNOSIS o f a lc o h o lis m TABLE 3. PERCENTAGE OF SUBJECTS WHO SELECTED PSYCHOSOCIAL DIAGNOSES ON THE SIMULATED PATIENT Very Somewhat Somewhat Very Diagnosis Likely Likely Intermediate Unlikely Unlikely Missing Alcohol problem 32 33 17 15 4 0 Anxiety d iso rd e r 28 35 24 11 0 2 Depression 23 44 19 11 3 0 Malingering 0 0 1 17 79 3 Personality disorder 3 7 16 24 46 3 Somatization disorder 4 8 5 26 53 2 Follow-up Questionnaire TABLE 4. DIAGNOSES OF ALCOHOL PROBLEM, ANXIETY Several weeks